I left clinical medicine for many reasons, but one of the most important is that caring for patients had become an endless slog of fighting administrators and other doctors. What did we fight about? Money, of course. Administrators did not want to spend it, and doctors did not want to risk doing work for which they might not be paid. I was afraid that one day, because I wasn’t up for a fight, one of my patients would be hurt. I had an experience shortly before I left practice that crystallized those fears.
A young woman who was 6 months pregnant called me one night when I was at the hospital. She had had pain in her leg for the past 2 days and the pain was getting worse. It wasn’t just that the pain was stronger; she had noticed that the pain appeared to be extending up her leg. First only the inside of her calf hurt, now the inside of her calf and her thigh hurt. I told her that she needed to come to the hospital because I was concerned that she might have a blood clot in her leg.
Blood clots in the leg (deep venous thrombosis or DVT) are potentially quite dangerous, and known to be more common in pregnancy. The danger of a DVT is that a piece of the clot in the leg can break off and travel to the lungs where it can cause death.
She arrived around midnight and I went to examine her. There are 5 classic signs of DVT and she had none of them. Her leg was not swollen, she had no tenderness over a major vein, the affected leg was not warmer, the skin over the vein was not discolored, and moving her foot in the prescribed way did not produce the pain typically associated with a DVT. Nonetheless, I had a bad feeling about this woman, and, over the years, I had learned to pay attention to bad feelings.
I explained to the patient that she had none of the signs of a DVT, but I was still worried. I wanted to get an ultrasound study of her leg to be absolutely certain that there was no blood clot. I apologized in advance, since it was unlikely that she had a blood clot, but blood clots are very dangerous and I wanted to be sure. The patient understood and agreed.
I called the radiologist on call and explained the story. I was very careful to point out that the patient had none of the classic signs of DVT, but I wanted the study anyway.
“No,” he said.
“Excuse me,” I replied. “I think I didn’t hear you correctly.”
“No,” he repeated. “I’m not going to scan her leg because she has none of the classic signs of a DVT.”
“Yes,” I said, somewhat exasperated. “I’m aware of that. I just told YOU that she has none of the classic signs, but I wanted to make sure.”
“Well, I’m not doing it because I won’t get paid.” He continued, “A scan in the middle of the night is an emergency and the insurance company will not pay for the scan unless it meets the criteria for an emergency scan. She must have some of those signs of a DVT or they won’t pay.”
We argued back and forth for a while, but he would not budge.
“Okay,” I said. “Just spell your name for me.”
He was puzzled. “Why do you need to know how my name is spelled?”
“Why? Because I am writing at the top of the very first page of the chart.” I cheerfully replied. “That way, when she walks out of the hospital and drops dead, they’ll know just whom they should sue.”
Silence.
“Well, if you’re going to be THAT way about it, I’ll scan her leg,” he said, “but I’m not going to do it right away.”
“Suit yourself,” I replied. “Just scan her leg before the morning.”
That exchange took place at 1 AM. I told the patient that we would have to wait for the scan, and I went to lie down.
At 5 AM my phone rang. The same radiologist was on the line, but now he sounded rather meek.
“Dr. Tuteur? Dr. Tuteur, I just wanted you to know that she has a blood clot in her leg extending from her ankle, up through her calf and thigh, right into her pelvis.”
Not only did she have a DVT, but she had the worst one either of us had ever seen. She almost certainly would have died from a pulmonary embolus if we had sent her home. Instead we immediately began treating her with blood thinners. She stayed in the hospital for two weeks, went home having learned to give herself shots of blood thinner, and ultimately did great. She delivered a healthy baby and had no further problem with blood clots.
Nonetheless, I was shaken up by the experience. She had only gotten the appropriate treatment because I had been willing to fight with the radiologist. In some ways, it had been a matter of luck. I wasn’t busy with other things; the radiologist had aggravated me, and was determined to prevail. I was uncomfortably aware that had circumstances been different, I might have failed to force the issue, and the patient would probably have died.
Why did the radiologist refuse to do the scan? He was simply responding to the incentives and punishments put in place by the insurance company. They didn’t want to pay for emergency scans so they made the requirements onerous. The insurance company was not wrong in assuming that patients without classic signs of DVT probably don’t have one, and they didn’t want to pay for needless scans. The radiologist was not wrong in assuming that this patient didn’t have a DVT and in assuming further that if he did the scan he would not be paid for it.
Almost everyone who has health insurance has fought with the insurer at some point because the insurance company has refused to pay. If you’ve done so know you just how frustrating that can be and how much time it takes. Doctors fight with insurance companies all the time, both to get approval for tests and procedures that patients need, and to get paid for visits, tests and procedures that have already occurred.
Most people don’t realize that doctors are often forced to fight with each other. The perverse incentives and punishments of the existing insurance system mean doctors who are trying to treat a patient must argue with other doctors who fear they will not be paid for their work. Sometimes, rather than fight to the bitter end, a doctor will give up and a patient won’t get a test or treatment that she needs. And sometimes, giving up could have fatal consequences.
